HCPCS stands for Healthcare Common Procedure Coding System (HCPCS). For Medicare and other health insurance programs to ensure health care claims are processed in an orderly and consistent manner, standardized coding systems are essential. The HCPCS Level II code set is one of the standard code sets used by medical coders and billers for this purpose. The other, HCPCS Level I, is comprised of CPT (Current Procedural Terminology), copyrighted by the American Medical Association (AMA).

Sometimes described as the “hall closet of coding,” HCPCS Level II serves several needs. The HCPCS Level II code set is made up of five-character alpha-numeric codes representing primarily medical supplies, durable medical goods, non-physician services and services not represented in the Level I code set (CPT®). HCPCS Level II includes services such as ambulance, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) when used outside a physician’s office. It is also used as an official code set for outpatient hospital care, chemotherapy drugs, Medicaid and other services. The Blue Cross Blue Shield Association and the American Dental Association (ADA) post their procedure codes as part of HCPCS Level II. The Centers for Medicare & Medicaid Services (CMS) often uses HCPCS Level II to post codes for the tracking of demonstration projects and new technologies.

The development and use of HCPCS Level II began in the 1980s. In 2003, the Secretary of Health and Human Services (HHS) delegated authority under the Health Insurance Portability & Accountability Act of 1996 (HIPAA) legislation to CMS to maintain and distribute HCPCS Level II codes. The code set is updated quarterly based on public input, which includes feedback from providers, manufacturers, vendors, specialty societies, the ADA, Blue Cross and others.

We get asked frequently on who is a good resource for a Medical Practice. We have comprised a list [specific in some areas to the State of Texas as that is where our business originates from]. Below is a list that will help you get started if you are working or interested in the Medical Field.

Blogs (these change depending on your needs at the time and or projects you are involved in and therefore some of these may not be applicable at all times)

Any others you feel are pertinent to your industry or area of expertise!

Stay informed on the changes in the industry to improve your viability and health of your practice. Take classes, attend seminars, and share what you lead with your team. Together you can be excellent in your industry as a Physician, Medical Practice Administrator, Medical Biller, Medical Coder and Nurse!

In part of our Question & Answer Series, today we address a common question about how to do billing when you are covering for another physician.

Q: If I am covering for another physician and see some of his/her patients during his/her absence, are these patients considered new or established?

A: The CPT guidelines specifically address this in the E/M services guidelines section in the front of the CPT manual, under the heading “New and Established Patient”. “In the instance where a physician is on call for or covering for another physician, the patient’s encounter will be classified as it would have been by the physician who is not available.”

So what does this mean? Let’s use an example. Physician A is on vacation and Physician B is taking Call Coverage while the physician is out of town. Patient makes an appointment to see On Call Physician (Physician B). Patient is established with Physician A and would have seen Physician A except he/she is out of town. Therefore the visit is billed as an Established Patient.

Each phase is the prerequisite for the next. Acquiring physician “buy‐in” must be accomplished in order to proceed to the planning and implementation phases. Because many physicians don’t know what they need to know about ICD‐10 in order to implement, analyze, and make informed choices, most practices are currently in Phase One: Engaging and educating physicians and staff. Take the time to create the foundation for the awareness and education necessary to achieve transition success and ensures you know ICD‐10 and that it is an opportunity for your organization and not a predicament.

Write your boss a letter like this:

“Doctor, thank you for all you do. Thank you for taking such great care of your patients and for taking such great care of your staff. We appreciate you and will do whatever we can to ensure the success of our practice. You always said
we could come to you if we had some thing really important to talk to you about. Well…this is really important.

As you know, we are talking about getting the practice ready for the ICD‐10 transition. You have committed budget to make sure we receive proper training. We are scheduling extra hours so we can have time to learn the new system. We are working with our IT vendors and business partners to make sure our software has been tested and ready to submit claims. We have made a good plan. Everything will be ready but we are concerned. Without you capturing the new documentation elements in order for us to be able to submit a properly coded claim, all the planning, budget, and new technology will be wasted. All the training hours and time away from our daily duties will be for naught. You see, it all starts with you. If you don’t document, all the planning, training, and technology in the world can’t help us.

The new codes are SO specific, documentation elements you’ve never had to capture before must be recorded or we can’t submit a claim. Denied claims due to insufficient documentation and therefore unspecific codes will cause a
rippling effect that means we have to chase you down in order to re‐submit. We are already so busy with our day‐to‐day duties it will be difficult to find time to do the extra work that would not have been necessary had you just recorded what was needed in the first place. I am asking you to do this for us but mostly…this is for you. We want you to continue to be able to give amazing care to our patients and to us. We want you to continue to be successful. We want you to know we care enough to write this note to you in the first place.

So, Doc, we promise we’ll be ready. All we ask is this. Help us help you.”
– Letter written by CPTICDPros.com

GEMs: “General Equivalence Mapping” is an approximate conversion and reference mapping system that attempts to include all valid relationships between the codes in ICD‐9‐CM and ICD‐10‐CM. The relationships can be “one to many,” “many to one,” and in some cases, “one to one.” GEMs is an excellent tool to be used for ICD‐10‐CM staff training and chart auditing.

HIPAA: Health Insurance Portability and Accountability Act of 1996 established not just new rules for ensuring the privacy of health records but also set standards for the electronic transaction of interchanged health data.

HHS: The U.S. Department of Health and Human Services.

ICD‐9‐CM: The Diagnosis Coding lexicon currently in use. It is outdated, inflexible and many categories are full. ICD‐9‐CM contains approximately 13,000 diagnosis codes using a 5 numeric character structure and is electronically communicated using the traditional v.4010 data format.

ICD‐10‐CM: The Diagnosis Coding lexicon mandated for use on Oct. 1, 2014. Developed by World Health Organization (WHO), and used in most industrialized nations, this code structure requires a new data format (v.5010) because it contains up to 7 alphanumeric characters unlike the 5 numeric characters used in ICD‐9‐CM. Comprised of approximately 68,000 codes, it requires providers to code and document to much greater “specificity”.

ICD‐10‐PCS: For use in Inpatient Hospital procedure coding only. Physician outpatient settings will continue to use CPT‐4 to report procedures and services.

O.N.C.: Stands for the Office of the National Coordinator for Health Information Technology and is a division of the U.S. Department of Health and Human Services (HHS). Under ONC, there are three bodies that can certify Electronic Medical Record technology for “Meaningful Use”.

Placeholder: When a seven character ICD‐10‐CM code requires a seventh character but the sixth position character has no function (e.g. no category, etiology or location), a “placeholder” consisting of the letter “X” is inserted in the sixth character position in order to hold that place in the code so that a seventh character can be used.

R.A.C. Audit: Recovery Audit Contractor ‐ The RAC Program’s purpose is to reduce improper Medicare payments and implement actions to prevent future improper payments. The demonstration program in 3 states started in 2005. 3 more states were added and by 2008, $1.03 billion were recovered from improper payments.

Role Based: Used to describe a type of training strategy that focuses the amount and type of training on job classification rather than general training for an entire group. In this context for example, you should consider a different level of training for your physicians (documentation training) than for your coding staff (full ICD‐10‐CM training).

Sequela: An aftereffect of a disease, condition or injury. Also called a “late effect.”

Specificity: In this context, “specificity” is a term used to describe choosing the diagnosis code that is the most descriptive possible given the available provider documentation.

V.5010: An electronic data reporting format scheduled replacing V.4010 on Jan. 1, 2012. Electronic testing of transactions using V.5010 commenced on Jan. 1, 2011. This new data format is required because the new ICD‐10‐CM codes are comprised of up to 7 alpha numeric characters and the old data format currently in use (v.4010) is unable to accommodate ICD‐10‐CM. (On Nov 17, 2011 CMS announced a 90‐Day period of enforcement discretion.)

W.E.D.I.: Comprised of a cross section of the health care industry, the Workgroup for Electronic Data Interchange (WEDI) is the leading authority on the use of Health IT to improve healthcare information exchange in order to enhance the quality of care, improve efficiency and to reduce costs of the American healthcare system. Formed in 1991 by the Secretary of Health and Human Services (HHS), WEDI was named in the 1996 HIPAA legislation as an advisor to HHS and continues to fulfill that role today.

WHO: World Health Organization is made up of representatives from numerous countries that create policy and develop health programs to be adopted on a world‐wide basis. The WHO developed ICD‐10.

Each person approved for Medicaid benefits gets a Your Texas Benefits Medicaid card. However, having
a card does not necessarily mean the patient has current Medicaid coverage. You must still verify
eligibility. There are several ways to do this:

Important: Do not send patients who forgot or lost their cards to an HHSC benefits office for a paper
form. They can get a new card mailed to them by calling 1-855-827-3748. Medicaid members also can go
online to order new cards or print temporary cards. For instructions, visit http://www.YourTexasBenefits.com
and click Learn more about the Your Texas Benefits Medicaid card.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 authorized the implementation of the Texas Medicaid Electronic Health Record (EHR) Incentive Program. The Medicaid/CHIP Division of the Texas Health and Human Services Commission (HHSC) began making incentive payments to eligible providers and eligible hospitals in 2011 for the adoption, implementation, upgrade, and meaningful use of certified electronic health record technology.

The HITECH Act requires states to conduct audits of payments to providers and hospitals participating in the incentive program. HHSC has contracted with the CPA firm of Davila, Buschhorn & Associates, P.C. to conduct audits of incentive payments on behalf of the State.

Representatives of Davila, Buschhorn & Associates, P.C. will be contacting providers who have been selected for audit. If you receive a notice of audit, please respond within ten (10) days with all requested information. The information you provide will be used for the sole purpose of the Texas Medicaid EHR Incentive Program audits.

Under the provisions of the HITECH Act, State Medicaid programs are establishing EHR Incentive Programs. These programs provide for incentive payments to certain health care professionals and hospitals that meet specific eligibility requirements when they adopt, implement, and meaningfully use certified EHR technology. To be eligible for incentive programs, health care professionals and hospitals must fall within the defined classifications and meet minimum Medicaid patient volume thresholds. Providers can determine whether they are eligible at this link.

Eligible professionals and hospitals must also meet meaningful use criteria. Over time, meaningful use criteria will be broadened. Minimally, a meaningful user of certified EHR technology must meet these three requirements:

Demonstrate use of certified EHR technology in a meaningful manner, including e-prescribing

Demonstrate connectivity to other providers to improve access to the full view of a patient’s health history

Use certified EHR technology to submit, in a form and manner specified by the Secretary of HHS, information on clinical quality measures and other measures

The final rule on specific meaningful use criteria was released on July 13, 2010. It outlines in greater detail what participating providers will need to do to qualify for the Medicaid EHR incentive payments. The final rule can be reviewed: http://www.gpo.gov/fdsys/pkg/FR-2010-07-28/pdf/2010-17207.pdf

To qualify for payment physician has to self certify, indeed, but responsive to the many questions they received on this issue (and most of the questions they received were on this singular issue), CMS explained they view the requirement as a two step process. First one must self-attest but then (as the second step) one has to support the self-attestation. So they suggest that they are not really defining it as ‘self-certification’ in a conventional sense. Further, no one can attest on behalf of the physician – physicians are required to do that on their own.

E&M Codes Identified in the NPRM:

Final rule now clarifies that states are not required to provide payments for codes in that range that are not otherwise eligible for payment under their state plan. Also clarifies that the 2009 base payment amount for codes added to the E&M range since 2009 and currently reimbursed by the state will be zero. Additionally recognizes that some states allow providers to bill using local codes – higher payment will be available for services billed using these codes if the state as part of the required state plan provides a crosswalk of those codes to the specified E&M codes (so they can continue to use the local codes, but they have to provide a crosswalk that will be approved or rejected by CMS as part of the SPA approval process).

Additional Parameters of Payment:

Final rule defines 2009 base Medicaid state plan rate as excluding performance based supplemental payments such as bonus, Pay for Performance, and incentive payments since they are not part of the fee schedule payments. However, it makes clear that volume based payments such as those made to physicians associated with certain academic medical centers must be acknowledged as part of the base rate. As required by statue, the final rule continues to provide for 100% FMAP on the differential between the 2009 Medicaid state plan rate and the applicable 2013 and 2014 Medicare rates. States that have lowered their rates since 2009 will receive federal match at the regular FMAP for the difference between the 2009 rate and the existing lower state plan rate. There are no waivers or exceptions possible.

Identification of the 2013/ 2014 Medicare Fee Schedule Amount:

CMS just published the final rule establishing the Medicare rates for CY 2013. Under current law, the Medicare conversion factor is expected to be $25 unless Congress intervenes to adjust the conversion factor upward. The conversion factor currently is $34. In 2009, the conversion factor was $36, therefore it appears that states will be expected to pay rates in 2013 for codes identified in the final rule that are developed using the 2009 conversion factor and 2013 RVUs.

The final rule no longer requires that states make all Medicare service and locality adjustments although they can do so if they wish. States can choose to pay all services as the Medicare office rate (non facility rate) as opposed to paying at facility rate when service is provided in a hospital setting. Can also choose to pay each E&M code at a rate that represents the Medicare mean over all counties rather than pay the Medicare rate applicable to specific geographic location. Continues to permit state flexibility in determining whether to and how often to update rates to conform to changes in Medicare physician fee schedule. Rule also clarifies that higher payment may be made as adjustments to rates or if in a lump sum basis – no less frequently than quarterly and these additional reconciling amounts methodologies will be specified to the state plan. Rule continues to require payment for codes not reimbursed by Medicare using a CMS developed fee schedule that will be based on the recommended RVUs and the CMS published conversion factor.

SPAs:

Final rule continues to require that states submit SPAs to implement the payment increase but now indicates that CMS will provide a template. The rule now indicates that SPAs will be required to specify (1) whether the state will make a site-of-service adjustment or reimburse all codes at the Medicare rate applicable to the office setting, (2) whether the state will make all Medicare locality adjustments or use a statewide rate per code that reflects the mean value over all counties of the Medicare rates (3) the manner in which states will make higher payment (whether as a fee schedule or aggregate supplemental payment ) and (4) the codes which will be paid by the state at the higher rate and the codes that have been added to the fee schedule since 2009. If the state does not use HIP AA compliant codes, the SPA must provide a crosswalk to the covered E&M codes.

The final rule confirms that the State plan requirement applies – meaning the SPA may be effective of the first day of the calendar quarter in which it is submitted, so states will have until March 31, 2013 to submit their SPAs Then CMS will have 90 days to review the SPAs and approve, deny or request additional information. 100% FFP will not be available for eligible primary care vaccine administration until the SPA is approved. CMS will work with states to expedite approval of the SPA. CMS will also provide a template to facilitate this requirement. No payment will be dispersed until the SPA is approved but, again, CMS believes the template will greatly expedite the development of the SPAs. MDES (the system that states report Medicaid expenditures) has been modified so that it has separate lines to report services eligible for the 100% match. There is also separate reporting for FFS payment and managed care payment.

Program Evaluation:

Rule requires that states submit to CMS at such time/in such form that CMS specifies information relating to participation by eligible physicians and use of E&M codes described in regulation as of 7/1/09 and for CY 2013. This data will help evaluate the impact of the rule on access to services.

Managed Care (Camille Dobson, Senior Policy Advisor for MMC):

For states that use a managed care delivery system, CMS revised section 438804 from the NPRM to require states to submit and receive approval from CMS for two methodologies (1) for identifying the 2009 base line rate for primary care services that were in capitation payments at that time and the differential in capitation rates between that amount and what they are paying in 2013 or 2014 that is eligible for 100% FFP. CMS made this revision because they determined, after receiving comments, that it was important to have a separate explanation of the 2009 base year rate for primary services since there are states that had populations or services that were not in managed care in 2009. In order to better evaluate the amount of difference in the payments that were eligible for 100% of FFP, they are now working with states on how to do this – as well as with Deloitte, which whom they have contracted for technical assistance.

The second change from NPRM is that the timeline is extended for submitting those methodologies and receiving CMS approval – thru end of first quarter of 2013 (original deadline was 1/1/13). This also synchs-up with the timeframe for submission of the SPA. CMS staff in regional offices will review and approve both of those methodologies to ensure states are using the most accurate and reasonable data available to accurately identify the amount eligible for the 100% federal match. Once those methods are approved, CMS will follow rapidly (hopefully) with approval of managed care contract amendments and rate setting documentation that reflect those managed care methodologies. Once states receive approval of contracts AND rates, payments will be made retroactively to 1/1/13 to the health plans. CMS gave flexibility to the states on how to disseminate payments to primary care providers, recognizing the number of different delivery systems that exit in managed care plans but they are clear that the benefit of the increased payment must go to the provider. Much like FFS: documentation must be provided by the plans to the state that the requirements of the rule are carried out. CMS is not specifying how that documentation or reporting must occur but states are required to specify that in their health plan contracts to substantiate that the primary care rate was delivered to eligible providers. Plans must also make available to the state for verification of payments for any audits or reconciliation processes and also for the evaluation component.

Vaccines

Section 1202 of ACA specifically identifies vaccines as being included in the payment increase – they are an integral part of the practice of primary care providers. More importantly, the inclusion aligns payment structure for vaccines and will hopefully result in increased provider participation and access to pediatric vaccines for children in Medicaid. Payments will be made at the lesser of the VFC regional vaccine for children or the Medicare physician fee schedule rate. Because the coding change for vaccines took place in 2009, states will have compute the vaccine administration code value – the formula to do this was included in the final rule. However, if states can show to state plan what was paid for vaccine administration codes on 7/1/09 – states can use that rate and will not have to develop another. The SPA template includes a section on vaccine administration and each state mush complete this template before it can receive increased payments. Coding change also added a code for additional components in a combination vaccine. The VFC program only allows a single payment for each shot administered and so the VFC doesn’t pay for this additional code. Here, the VFC rules also apply to the final rule.

The final rule also included an updated fee schedule for the VFC program. It has not been updated since 1994. There were no other changes to VFC program, so states continue to have the flexibility to determine their state’s regional maximum fee.

Doctors can breathe a sigh of relief as a Medicare pay cut of nearly 30 percent is narrowly averted — at least temporarily. On New Year’s Day, Congress approved a “fiscal cliff” bill that includes a one-year delay of the scheduled Medicare pay cut — to the tune of 26.5 percent — due to the flawed sustainable growth rate (SGR) formula.

The bill also includes a two-month delay of an additional 2 percent cut to Medicare pay due to across-the-board spending cuts scheduled as a result of Congress’ failure to reach a budget deficit deal in 2011, according to Medscape.

While the AMA praised Congress for avoiding the massive pay cut, it criticized its continued failure to identify a permanent SGR fix.

” … Congress’ work is not complete; it has simply delayed this massive, unsustainable cut for one year,” AMA president and psychiatrist Jeremy A. Lazarus said in a statement. “Over the next months, it must act to eliminate this ongoing problem once and for all.”

Lazarus went on to say that the “last-minute action” to delay the SGR cut is a “clear example of how the Medicare program is increasingly unreliable for physicians and patients.”

If you follow my blog, you would have read a post here about my latest Beta Client experience. This is not my first time to ever do this and I have never had a previous bad experience in being a Beta Client; however there is always a first for everything.

Anytime something doesn’t go as planned, I always try to evaluate it. With that, here are 5 Lessons I learned from the latest Beta Client experience:

Don’t take people at their word. People change. When the going gets tough, many times people quit and don’t fulfill their commitments and follow through on their promises. This means even great Entrepreneurs that state they will do whatever it takes to make something happen.

Define expectations in writing of what a Beta Client means and who will be doing what. Even though someone says they will work with you jointly on a project, if they don’t do what they said they will do, you need something to fall back on. No assumptions on what that means.

Don’t expect the other party to put in as much “free” services as you do. You will always have to give 150% more than the other party does. Don’t go into a deal unless you are willing to be the one doing 150% of the work (or more).

Be sure to have a backup plan in case the current plan doesn’t work out as anticipated. You have heard the saying “Don’t have your eggs all in one basket”. Another wards, don’t be so into this deal that you don’t have another option if it falls through.

When the deal is off, realize its a done deal and move forward. Don’t cry over spilt milk. It is already spilt and no way to get it back into the cup.

Working with Physician’s offices that are start-ups, means they do not have the same capital to build their Medical Practice with. This places challenges on many fronts when trying to find ways to be compliant with the Federal Regulations and making the Practice efficient and profitable.

In seeking to assist a client with the implementation of a Practice Management System with an Electronic Medical Records System (EMR), we (the software consultant for my client, my client and I) opted to be a Beta Client for a Texas-based company. Their system was built for Chiropractor’s and they wanted to be able to advance and take their product to the next level. The system was web-based, very user-friendly and had met the Meaningful Use requirements and was certified. The company agreed to provide support and enhancements to meet the criteria needed by our specialty in exchange for us building the database, providing the feedback and testing the product for free along with a very low monthly maintenance fee.

After 5 months of working in the database, building the templates, creating the profiles, loading the CPT Codes, creating the Fee Schedules, loading the ICD9 Codes, inputting our patient base, etc the vendor has reneged on their agreement with us. Their decision really made this a tough week to learn that they are not willing to fulfill their part of the deal with us. The hard-core facts of the amount of time I have spent on something I won’t get a return on and the money spent to pay employees to load information in a system that we won’t be using, is gone. We are back to square one, 4 months into a new year, with no more headway now then we were in the Fall of 2011 towards meeting Meaningful Use. This is a huge setback and a difficult situation that I currently am not aware how I am going to address, other than a meeting this next week with the Software Consultant and my client to discuss our options.

Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced Monday, April 9th, a proposed rule that would establish a unique health plan identifier under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The proposed rule would implement several administrative simplification provisions of the Affordable Care Act.

The proposed changes would save health care providers and health plans up to $4.6 billion over the next ten years, according to estimates released by the HHS today. The estimates were included in a proposed rule that cuts red tape and simplifies administrative processes for doctors, hospitals and health insurance plans.

“The new health care law is cutting red tape, making our health care system more efficient and saving money,” Secretary Sebelius said. “These important simplifications will mean doctors can spend less time filling out forms and more time seeing patients.”

Currently, when health plans and entities like third-party administrators bill providers, they are identified using a wide range of different identifiers that do not have a standard length or format. As a result, health care providers run into a number of time-consuming problems, such as routing errors of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility.

The rule simplifies the administrative process for providers by proposing that health plans have a unique identifier of a standard length and format to facilitate routine use in computer systems. This will allow provider offices to automate and simplify their processes, particularly when processing bills and other transactions.

The proposed rule also delays required compliance by one year– from Oct. 1, 2013, to Oct. 1, 2014– for new codes used to classify diseases and health problems. These codes, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes, or ICD-10, will include new procedures and diagnoses and improve the quality of information available for quality improvement and payment purposes.

Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date. The proposed change in the compliance date for ICD-10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.

The proposed rule announced today is the third in a series of administrative simplification rules in the new health care law. HHS released the first in July of 2011 and the second in January of 2012, and plans to announce more in the coming months.

We will be doing more Blog Posts on the subject of Credentialing, but today’s is simply an overview for you to understand what it is.

Credentialing, as defined by Texas Administrative Code (TAC) §10.82, is the “process for selection and retention of network doctors and health care practitioners” (providers). Credentialing is the process of establishing the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy. The credentialing process is part of the required Quality Improvement Program described in 28 TAC §10.81 and Texas Insurance Code, §§1305.301-1305.304. All certified workers’ compensation networks are required to document, create policies and procedures, and develop written criteria for credentialing network providers.

The initial credentialing process may begin with a provider submitting a completed Texas Standardized Credentialing Application to the Insurance Company and Network in which they wish to participate. The Credentialing Department and/or Committee will verify items such as the applicant’s work history, current professional liability insurance, education, board certification (if applicable), history of loss, sanctions or other disciplinary activity. The process may also consist of an on-site visit to assess the applicant’s location of practice or facility. The applicant must be notified of the credentialing committee’s decision no later than 60 days after the decision. The WCNet is required to re-credential each participating credentialed provider every 3 years.

Many health care facilities, institutions and providers conduct their own credentialing, through this is a service that can be paid for and done by a credentialing specialist or electronic service, with review by a medical staff or credentialing committee. It may include granting and reviewing specific clinical privileges, and medical or allied health staff membership.

As Texas is not an “any willing provider” state, the WCNet is not required to contract with a provider applicant. However, pursuant to 28 TAC §10.82, a provider has the right to review the information submitted to support the credentialing application, correct erroneous information and the right to be informed of the status of their credentialing or re-credentialing application.

The process is generally an objective evaluation of a subject’s current licencee, training or experience, competence, and ability to provide particular services or perform particular procedures.

Personnel credentialing is typically undertaken at commencement of employment (initial application) and at regular intervals thereafter (reappointment). Credentialing of vendors or other organizations may begin prior to the purchasing process and be repeated regularly.

Do you do your own credentialing or do you hire someone else to do it?

Each states has its own guidelines and regulations set forth in various forms of the Healthcare Industry. The Texas Department of Insurance has guidelines on specific requirements that are needed on a HCFA1500 in order for it to be considered as a Clean Claim. You can review those documents here on the Texas Secretary of State website.

Do you wonder if the Texas Clean Claim Requirements apply to you? You can read and find that information here.

A clean claim must be submitted in order for the Prompt Pay Guidelines to apply. We will review those with you soon!

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment. That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012. I know. Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain. However, I hope by now you are making great strides in the conversion. If not, I am sorry. I wish I could fix it with a magic wand, however, I can’t. I can provide you a few pieces of information that might help you get some cash flow turnaround quickly and will be posting a few tips on Version 5010 that will provide you some resources to help you make headway through to get some answers to your problems.

The deadline was set for enforcement of Version 5010 on March, 31, 2012…however last week CMS released an update that this has been extended to June 30, 2012. However, we recommend that if you have not begun to convert to the Version 5010 format, you should start today and be finalizing your upgrade this week because there is no reason to put it off. Once you have finished your upgrade to Version 5010, you’ll need to ensure your system continues to run properly. Providers should look for the following indicators to make sure there are no problems with their system upgrade:

An Increase in Rejections or Denials of Claims
An increase in rejections or denials of claims may be an indication that there is not sufficient or correct data provided to meet Version 5010 standards. Partners, such as payers, also have a part in correcting this issue, since forwarding, converting, or formatting data can result in rejections or denials. Monitor your claims closely to determine the reasons for rejection or denial of claims and coordinate with payers to ensure that data is properly processed to avoid claim delays.

Issues with Non-Electronic Funds Transfer (non-EFT) Payments
Version 5010 includes changes to claims formatting, including a full nine-digit ZIP code and inclusion of provider billing address. Submitting claims with only a five-digit zip code will result in rejection. If your practice has not submitted the correct billing or mailing address as part of your Version 5010 claim, your non-Electronic Funds Transfer (non-EFT) payments or Explanation of Benefits (EOBs) information may be mailed to the wrong physical location. Make sure to coordinate with your payers to verify how they use enrollment information and process claims data, as this will also be affected by the mailing address on file. Being diligent in tracking your claims and remittances (EOBs) will help identify and address any issues that may arise.

Formatting Discrepancies with Partners
Your trading partners should also have upgraded to Version 5010; however, your organization may interpret the new standards differently than your external partners, which can result in rejected claims. You should coordinate with your payers and/or clearinghouse to determine any gaps or discrepancies in claims submissions. You and your partners should monitor claims that are automatically transferred between payers and address new response formats or data as claims are processed.

Read the information on the Version 5010 section of the CMS website to find helpful fact sheets on the upgrade to Version 5010 and previous listserv messages discussing the Version 5010 upgrade.

The National Institute of Standards and Technology (NIST) has made available a security toolkit in an effort to help organizations better adhere to HIPAA compliance mandates.

“The NIST HIPAA Security Toolkit Application is intended to help organizations better understand the requirements of the HIPAA Security Rule, implement those requirements, and assess those implementations in their operational environment,” the NIST states.

The toolkit is designed to provide guidance for not only covered entities, but their business associates and any other entity impacted by federal HIPAA compliance requirements.

“Target users include, but are not limited to, HIPAA covered entities, business associates, and other organizations such as those providing HIPAA Security Rule implementation, assessment, and compliance services. Target user organizations can range in size from large nationwide health plans with vast information technology (IT) resources to small health care providers with limited access to IT expertise,” NIST continued.

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment. That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012. I know. Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain. However, I hope by now you are making great strides in the conversion. If not, I am sorry. I wish I could fix it with a magic wand, however, I can’t. I can provide you a few pieces of information that might help you get some cash flow turnaround quickly and will be posting a few tips on Version 5010 that will provide you some resources to help you make headway through to get some answers to your problems.

You are having major cash flow crisis issues. You don’t know what the freake is up with your claims. You don’t know if your carrier is getting them because your Carrier Reports and Carrier Responses may be inconsistent, your software vendor may or may not know what is wrong or how to resolve, and you are frustrated. Have you considered dropping your claims to paper to get them to the carriers? Yes, that does mean that it takes longer to get paid, but right now the concern is getting paid, right?

In December 2011, before 5010 Implementation Date, I advised all my clients to stock up on 1500 Claim Forms. One of them looked at me like I was insane and commented, “Why would we want to send paper claims?”. I reassured the client that I would rather be prepared and have the forms that would be needed in the event that we should have to drop our claims to paper and that the electronic submission format was the prime method we would use, but in the event we get backlogged with issues, we will need to get claims out the door so that we can get them processed, even if that adds a week to three weeks to the process, that is better than no process at all. Were they grateful that they followed my recommendation so that we could print a mountain of paper claims the 2nd week of January? You bet they were!

Documentation apart of the medical record has many aspects involved. Whether one has an intrinsic interest in medical records or not, everyone wants to get paid and, for most physicians, that still involves a bill, usually to an insurance carrier. Unfortunately, there are documentation requirements to get paid. Merely submitting a billing code is not sufficient.

The University of North Texas has summarized the minimum required documentation pretty well here in their Clinical Documentation and Compliance Manual, however we will outline a few of the important aspects of them below.

Every Patient Encounter should include:

reason for the encounter and relevant history;

physical examination findings and prior diagnostic test results;

assessment, clinical impression, or diagnosis;

plan for care; and

date and legible identity of the observer.

If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

Appropriate health risk factors should be identified.

The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.

The CPT and ICD9 codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

These are just a few of the very important things that must be included to maintain documentation and compliance.

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment. That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012. I know. Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain. However, I hope by now you are making great strides in the conversion. If not, I am sorry. I wish I could fix it with a magic wand, however, I can’t. I can provide you a few pieces of information that might help you get some cash flow turnaround quickly and will be posting a few tips on Version 5010 that will provide you some resources to help you make headway through to get some answers to your problems.

Are you aware of what has changed with 5010? Have you researched the areas that are affected with your specialty? Do you realize that if this data is not loaded correctly, your claims will not make it to your clearinghouse? Understanding the fields and how data is reported on a HCFA1500/CMS1500 Claim Form is a critical step to making sure your data is loaded correctly. The National Uniform Claim Committee has a document called the 1500 Claim Form Map to the Healthcare Professional 837 File. Click the link to download the latest version. It will help you trouble shoot your rejections when you need to know what loop and segment go where in your database!

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment. That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012. I know. Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain. I am sorry. I wish I could fix it with a magic wand, however, I can’t. I can provide you a few pieces of information that might help you get some cash flow turnaround quickly. The next few weeks I am going to try to post a few tips on 5010 and hopefully provide you some resources to help you make headway through to get some answers to your problems.

Who is your clearinghouse?

Do they have a newsletter?

Do they have a blog?

Do they have a discussion board?

Do they send you weekly tips and suggestions to improve your claims?

Do they have webinars for you to attend (either free of charge or at a cost)?

Have you utilized everything they offer?

The only way to know is to research it and find out. If you don’t know…google them and see where it goes. You are liable to learn a lot in a short time frame and maybe even get a nugget that will help you with a current problem you are experiencing.

The NUCC was created to develop a standardized data set for use by the professional health care community to transmit claim and encounter information to and from all third-party payers. It is chaired by the American Medical Association (AMA), with the Centers for Medicare & Medicaid Services (CMS) as a critical partner. The NUCC is a diverse group of health care industry stakeholders representing providers, payers, designated standards maintenance organizations, public health organizations, and vendors.

The NUCC was formally named in the administrative simplification section of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191 (P.L. 104-191) as one of the organizations to be consulted by the American National Standards Institute’s accredited Standards Developing Organizations (SDOs) and the Secretary of Health and Human Services (HHS) as they develop, adopt, or modify national standards for health care transactions. The NUCC was also named as one of the HIPAA Designated Standards Maintenance Organizations (DSMO) to maintain the HIPAA transaction standards. A DSMO Web site has been established to submit requests for changes to the HIPAA
implementation guides. For more information regarding the DSMO groups and the process for submitting change requests go to www.hipaa-dsmo.org. Therefore, the NUCC is intended to have an authoritative voice regarding
national standard content and data definitions for professional health care claims in the United States. The NUCC’s recommendations in this area are explicitly designed to complement and expedite the work of the ASC
X12N in complying with the provisions of P.L. 104-191. The NUCC is comprised of the key parties affected by health care electronic data interchange (EDI) – those at either end of a health care transaction, generally payers and providers. Criteria for membership include a national scope and representation of a unique constituency affected by health care EDI, with an emphasis on maintaining or enhancing the provider/payer balance in the original NUCC composition. Each NUCC member is intended to represent the perspective of the sponsoring organization and the applicable constituency. Representatives are responsible for communicating information between the NUCC and the group(s) they represent.
The following organizations serve on the NUCC as voting members:

The AAPC did a survey last week, which I participated in for each of my clients. I let you all know about it in this post. The results were released today and if you are interested, click this link and you can review the data. It is interesting if you care to know what everyone else is experiencing.

An Oklahoma provider was the first to receive EHR Incentive Program funds from Medicaid. She shares her story here on a letter she would write to Medicare and Medicaid Services if she could as follows: Dear Center for Medicare and Medicaid Services. She would send it, if they would listen. If they cared. It is worth reading.

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment. That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012. I know. Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain. I am sorry. I wish I could fix it with a magic wand, however, I can’t. I can provide you a few pieces of information that might help you get some cash flow turnaround quickly. The next few weeks I am going to try to post a few tips on 5010 and hopefully provide you some resources to help you make headway through to get some answers to your problems.

Who is your biggest Insurance Carrier? Is it a commercial insurance carrier or government program?

Do you know if they have the ability for you to file claims directly on their online portal? If so…have you considered this option? Did you know about 50% of them do?

Are you aware that claims are processed in 24-72 hours once submitted on this site and that you have a check within 7-10 days?

If the insurance carrier does not have an online portal to be able to submit claims to them, do you know if the insurance carrier has any free software you can use to submit claims? Medicare does. It is called PC ACE PRO 32. You have to have an EDI Agreement in place directly with them and get a unique submitter ID#; however, once you get that, claims are paid within 14days like clockwork. It is NOT a Practice Management system, it is simply a tool to submit claims…but if you are not getting paid through your clearinghouse it is a viable option to consider in the interim.

If I were to have given CMS any feedback on preparation for 5010, they should have made this an available option and a requirement that all insurance carriers have an option to be able to upload raw data directly to them and/or their clearinghouse along with a portal for online claim submission.